Vulvovaginal Disorders - Exam 3 Flashcards
What are some normal flora found in the vagina? Which ones are more common? What specific one?
Aerobes, anaerobes, and yeast
Anaerobes 10x greater than aerobes
lactobacillus!
What is the normal pH of the vagina? What is it post-menopause?
Normal vaginal pH - 4.0 - 4.5
Normal vaginal pH - 6.5-7
Why is a normal vagina acidic?
because anaerobes convert glycogen in vaginal mucosal secretions to lactic acid
What are some factors that can alter the vaginal flora?
age
menses
abx use
changes in reproductive tract
foreign substances
decreased overall health
poor eating habits
medications: OCPs, abx, steroids
immunosuppression
How does age affect the vaginal flora?
low estrogen levels = less Lactobacillus
Estrogen replacement restores vaginal lactobacilli
How does menses affect vaginal flora?
transient changes, mainly in first days
Menstrual fluid may nourish bacteria
What are changes in the reproductive tract that can alter vaginal flora?
hysterectomy and pregnancy
What type of foods can lead to alterations in the vaginal flora?
sugary foods!!
What are some ways to restore normal vaginal flora?
Avoidance of aggravating or predisposing factors
Antimicrobial regimen for treatment or prophylaxis of overgrowth
Probiotic dosing
How common is candidal VV? (vulvovaginitis) ____ is the MC type
75% will experience it at some point
Candida albicans
What are candidal VV associated with?
DM, HIV, obesity, pregnancy, Abx, steroids OCPs, bed bound
Intense vulvar pruritus +/- excoriations
Thick, white, “cottage cheese” discharge
Usually with minimal odor
candidial VV
What am I?
What is the pH?
candidal VV
mildly elevated pH: 4-5
What are the prep instructions to do a saline prep in candidal VV? What will it look like on the slide?
1 drop vaginal discharge with 1 drop normal saline
Apply coverslip and examine under microscope
Candidiasis - branching filaments, pseudohyphae
What are the prep instructions to do KOH prep in candidal VV? What will it look like on the slide?
1 drop discharge with 10% aqueous potassium hydroxide
Dissolves epithelial cells and debris and facilitates visualization of fungal mycelia (thread like hyphae)
**What is the gold standard for candidal VV dx?
culture is gold standard
What is the tx for candidal VV?
Topical or oral antifungals, boric acid, gentian violet
1-3 days of topical azole creams or a single dose of fluconazole
What is the tx for complicated cases of candidal VV? What is considered complicated?
7-14 days of topical therapy or 2 doses of oral fluconazole (1 dose today and a 2nd dose in 5 days)
need to culture to confirm diagnosis
Consider boric acid
complicated: 4+ episodes/yr, severe symptoms, non-albicans, uncontrolled DM, HIV, steroids, pregnancy
_____ therapy for candidal VV may provide the quickest onset for s/s relief
intravaginal antifungal cream
_____ and ____ treatments for candidal VV cannot be used in pregnancy
oral antifungal and intravaginal boric acid
_____ is available OTC and works better for non-candidal infections. What is a super important pt education point?
intravaginal boric acid
DO NOT TAKE BY MOUTH!! intravaginal only
_____ is available OTC and does NOT work well with other topical therapy, not studied in pregnancy
gentian violet
______ MOA inhibit enzyme for cell membrane synthesis
antifungal therapy
_____ MOA increase permeability of cell walls
nystatin
______ is the new oral azole. What is it’s indication? It can be combined with _____. What are the 2 MC SEs?
Oteseconazole (Vivjoa)
Only indicated for recurrent vulvovaginal candidiasis
fluconazole
HA, nausea
______ is the new drug in the triterpenoid class and has better long-term prevention of recurrent VV than azoles
Ibrexafungerp (Brexafemme)
_______ MOA inhibits glucan synthase enzyme, used to make cell wall
Ibrexafungerp (Brexafemme)
class: triterpenoid
What is the pt education for boric acid? What size? How much boric acid?
One capsule intravaginally (PV) QHS for 7 days
Size 0 gelatin capsules filled with boric acid (about 600 mg)
_____ MOA interferes with fungal metabolism
intravaginal boric acid
Gentian violet intravaginal should be _____ and removed _____. What is the pt education?
applied to a clean tampon
removed 3-4 hours after tampon insertion
Should not use tampons for menstrual
flow while performing this therapy
______ MOA may inhibit protein synthesis
Gentian Violet
What is the prophylactic treatment of candidal VV?
May use prophylactic antifungals for up to 6 months:
Azoles - PO 1x/week or PV 1-2x/week
Boric acid - PV once every two weeks
Gentian violet - PV/externally QD x 10-14 d, then PRN
What is the underlying cause of bacterial vag? What specific pathogen?
Overgrowth of abnormal bacterial flora, usually polymicrobial
Gardnerella vaginalis
Milky
homogenous
malodorous vaginal discharge, “fishy” that is worse after unprotected sex
ZERO to minimal inflammation
What am I?
What is it associated with?
What is the pH?
bacterial vaginOSIS (not -itis) this is a condition not inflammation
increased risk of preterm delivery
usually elevated: 5.5-7
**What will you see on saline prep for bacterial vaginosis? **What will you see on KOH prep?
saline prep: **“clue cells” - epithelial cells covered with bacteria
KOH: **fishy odor present or increased after KOH (“whiff test”)
What am I? What dx?
clue cell
saline prep for bacterial vaginosis
What is the tx for bacterial vaginosis?
metro (oral or vaginal) or clinda (oral or vaginal)
Tinidazole (Tindamax) and Secnidazole (Solosec) are used to treat _____ but not really due to high cost and CANNOT be used in preg pts. What drug class? Same drug class as the commonly used _____
bacterial vaginosis
Nitroimidazoles: drug class
metronidazole
______ MOA binds to and deactivates enzymes (give drug class)
Nitroimidazoles
includes: Metronidazole (Flagyl, Metrogel) or tinidazole (Tindamax) or secnidazole (Solosec)
**What is the tx for bacterial vaginosis in a preg pt?
should generally be treated with PO metronidazole or clindamycin
What is the DDI that is important to remember for Nitroimidazoles?
alcohol (up to 3 days after use)!!!!
others include: disulfiram (up to 2 weeks before/after use), anticoagulants, phenytoin, lithium
_____ MOA binds to ribosomes blocking protein synthesis
clindamycin
What are the SEs of clinda?
C. diff and pseudomembranous colitis
**______ is the most prevalent NON-VIRAL STD in the US. What is it?
**trichomonal vag
Unicellular flagellate protozoan
frothy
greenish
at times foul-smelling vaginal discharge
may have pruritus
may have urinary symptoms
What am I?
What is the PE finding?
What is the pH?
trichomonal vaginitis
May see “strawberry cervix”
usually elevated (pH 5-5.5 or higher)
What will you see on saline prep for trich? What is the most sensitive method for trich?
actively motile trichomonads
culture
What am I? What dx?
frothy vaginal discharge
trich
What am I? What dx?
strawberry cervix
trich
What is the tx for trich? What is the tx for resistant trich? What is one additional thing you need to do?
metronidazole OR secnidazole OR tinidazole
2 grams x 1 dose
resistant: tinidazole
Partner should also be treated! and screen for other STIs
What is the alternative but slightly more effective tx for trich?
metronidazole 500 mg orally BID x 7 d
(instead of 2 grams taken at 1 time)
usually asymptomatic
copious mucopurulent discharge possible
What am I?
Why is this dx concerning?
gonorrheal and/or chlamydial
15-20% develop upper tract disease (PID)
_____% of women with gonorrhea are asymptomatic. How do you dx?
80-85%
nucleic acid probe or culture of discharge
What will gonorrhea show up like on a culture report? What is the tx? What should you do next?
G-diplococci within leukocytes
single IM dose of ceftriaxone
also tx for chlamydia: doxy bid for 7 days
How do you dx chlamydia? What is the tx?
culture, immunoassay, nucleic acid or pap smear
doxy po bid for 7 days
alt: azithro
also need to tx partner!
What are some causes of noninfectious vaginitis? What is the tx?
topical irritants
allergens
atrophy
excessive sexual activity
poor hygiene, stress, sweat, heat
identification and removal of offending agent
What are some CAM treatments of vaginitis?
white vinegar douche
herbal combination douche
iodine douche
tea tree oil suppositories
probiotic supplements
What are the 2 different types of herpes? What is the percentage breakdown? Is it possible to spread the virus without an active lesion?
60% - HSV type 2; 40% - HSV type 1
YES!! can shed virus without active lesion
vesicles that become painful erosions or ulcers surrounded by an erythematous halo
What am I?
Likely to have _____ before
Name 2 additional symptoms
herpes genitalis
prodrome of tingling, itching, burning, flu-like symptoms
+/- inguinal lymphadenopathy
+/- urinary symptoms (dysuria, urinary retention)
**What is the tx for HSV on the first outbreak? **Recurrent outbreaks?
first outbreak: **7-10 days
recurrent: **1-5 days
valacyclovir, acyclovir
What is Condyloma Acuminatum
caused by?
genital warts aused by HPV, mainly types 6 and 11
white exophytic or papillomatous growth
Tend to coalesce and form large cauliflower-like masses
May also see flat lesions with granular surfaces
What am I?
What should you do before tx?
Condyloma Acuminatum
need to do pap and colposcopy b4 tx
consider bx
What are the tx options for condyloma acuminatum?
Provider - topical application of bichloracetic acid, trichloroacetic acid, podophyllin
may also use cryotherapy, electrosurgery, simple excision, laser
Patient - topical application of podofilox, imiquimod, topical interferon, or sincatechins
What virus causes molluscum contagiosum? What will microscopy show?
poxvirus
numerous inclusion bodies (molluscum bodies) in cell cytoplasm
What is the tx for molluscum contagiosum? What is the classic appearance?
desiccation, freezing, curettage, chemical cauterization, topical imiquimod
umbilicated appearance in the center
What pathogen causes syphilis? Classify it
Treponema pallidum
spirochete
What are the 4 different stages of syphilis? give a brief description. What 2 organ systems does syphilis go after the most?
Primary - lone painless ulcer (chancre) +/- lymphadenopathy
Secondary - generalized rash, malaise, fever
Latent - asymptomatic with positive serology
Tertiary - systemic involvement (e.g. cardiac, neural)
brain and heart
What is first line tx for syphilis? What is the tx for Primary, secondary, or <1 year latent syphilis?
PCN IM 1 dose
PCN IM 1 dose
What is the tx for Primary, secondary, or <1 year latent syphilis who have a PCN allergy and are NOT pregnant? What is they are pregnant?
doxy
strongly urged to use PCN (desensitization for PCN-allergic pts)
What is the tx for > 1 year latent, tertiary, cardiovascular syphilis?
PCN IM/wk x 3 wk (3 doses)
What am I?
chancre of primary syphilis
What am I?
generalized rash of secondary syphilis
Where are bartholin gland’s located? What is there job?
Located near vaginal orifice at the 4 and 8 o’clock position
Secrete mucus for lubrication
If bartholin gland’s are inflammed in a postmenopausal women, what should you be thinking?
may be cancerous, consider bx
What can a bartholin gland obstruction lead to?
secretion build up → cystic dilation → secondary infection → recurrent abscesses
Pain, tenderness, dyspareunia
Difficulty walking with adducted thighs
Usually will have fluctuant, tender mass
What am I?
What if it was cystic only?
Bartholin Gland Disease
cystic only - swelling with no pain or minimal discomfort, no systemic signs of infection
What am I?
Minimally inflamed bartholin gland cystic lesion
What am I?
When do you need abx?
Inflamed Bartholin gland abscess
only need abx if significant inflammation
or signs of systemic illness
What are the 2 first line treatment options for bartholin gland disease? Why do you NOT want to do _____
marsupialization or insertion of Word catheter
Simple aspiration or I&D only provides temporary relief and it will come right back
What is lichen sclerosus? What do they think causes it?
Benign, chronic, inflammatory disorder
multifactorial:
vitamin A deficiency
autoimmune
excess of elastase
decreased 5-alpha-reductase
______ is the most common non-neoplastic epithelial vulvar disorder
lichen sclerosus
What is the MC pt population for lichen sclerosus? What is the MC presenting symptom?
Usually in women >60 years
pruritus!!!
What is the typical characteristics and progression of ACUTE lichen sclerosus?
What am I?
acute lichen sclerosis
What is the typical characteristics and progression of CHRONIC lichen sclerosus? What is the characteristic PE finding?
Thin, wrinkled, white skin (“cigarette-paper”)
What am I?
chronic lichen sclerosus
What is the concerning complication of lichen sclerosus?
High rate of squamous cell cancer
need to bx!!
What is first line tx for lichen sclerosus? What if refractory? ____ can be used as adjunct treatment
Clobetasol propionate 0.05% (Dermovate)
intralesional injection
oral antihistamines at bedtime, topical emollient
What is the prognosis of lichen sclerosus?
CHRONIC disease so it will return if tx is stopped
topical steroids resolve symptoms in most patients
______ is benign epithelial thickening and hyperkeratosis. Due to _______. They are associated with _____
Lichen Simplex Chronicus
likely due to chronic irritation
associated with atopic disorders
Lichenified, scaly, localized plaque
Initially may present as red papules that later coalesce
+/- excoriations, hypopigmentation, or hyperpigmentation
Can develop secondary cellulitis
Patients usually complain of itching
What am I?
lichen simplex chronicus
aka this one will NOT cause permanent skin changes like lichen sclerosus just chronic inflammation
What am I?
How do you dx?
lichen simplex chronicus
bx: Required to rule out intraepithelial neoplasia or invasive CA
How will the bx be different when comparing lichen sclerosus and lichen simplex chronicus?
lichen simplex chronicus: Absence of dermal inflammatory infiltrate distinguishes from lichen sclerosus
What is the tx for lichen simplex chronicus?
_____ are mucocutaneous dermatosis and appear as sharply marginated flat-topped papules on the skin and less sharply marginated white plaques on the mucous membranes
lichen planus
mucocutaneous dermatosis: group of disorders primarily affecting the skin and mucous membranes, often involving inflammatory or autoimmune processes, and can manifest as blistering, ulcerating, or other skin and oral lesions
What is the tx for lichen planus?
aka steroids and bx
What am I?
Lichen planus
What am I?
lichen planus
______ are darkly pigmented flat lesion that may be mistaken for melanoma
Melanosis /Lentigo
What is a senile?
type of dark vulvar lesion that is small, dark blue asymptomatic papules
type of capillary hemangioma
When is it okay to see vulvar varicosities? What is the tx?
only during pregnancy!!! any other time it is concerning
tx not necessary unless there is a complication, supportive compression undergarments
if they persist post-partum, then can use sclerosing agent
What am I?
vulvar melanosis
What am I?
vulvar senile hemangioma
What am I?
vulvar childhood hemangioma
What is VIN? What is the MC pt population? Median age?
Vulvar intraepithelial neoplasia (VIN) often associated with multifocal lower genital tract disease
younger women who also have intraepithelial neoplasia somewhere else
median age is 40
VIN is strongly associated with _____ and _____ increases chance of high grade lesion
HPV (90%) and smoking increases risk
What is the MC presentation of preinvasive vulvar disease? What is the MC presenting symptom?
white, hyperkeratotic papules, can be single or multiple, flat or raised
pruritus!
What is the gold standard to dx Preinvasive Vulvar Disease?
inspection of vulva with colposcopy (with and without green filter) followed by biopsy of suspicious lesions
What am I?
What is the tx?
vulvar neoplasia
tx based on bx:
wide local excision or lasar
aka cut it out
**What is the follow-up schedule for preinvasive vulvar disease?
Thorough pelvic exam with colposcopy every 3-4 months until patient is disease free for 2 years
After 2 years - pelvic exam every 6 months
What is extramammary Paget’s Disease?
Intraepithelial neoplasia (adenocarcinoma in situ) May be extensive but mostly confined to epithelial layer
aka not going to spread deep into tissue just superficially across it
Who is the MC pt for Extramammary Paget’s Disease? What are the MC symptoms?
Caucasian women in 60s-70s
pruritus, vulvar soreness, velvety-red discoloration
**What is the classic PE finding in Extramammary Paget’s Disease?
“Red Velvet Cake” appearance
Eventually becomes eczematoid with maceration and development of white plaques
What am I? What dx? What is the tx?
red velvet cake appearance
extramammary paget’s disease
bx and then wide local excision, often requires complete vulvectomy
What is the recurrence for extramammary paget’s disease? What is the prognosis?
high chance of recurrence
If invasive, (-) node metastases - good prognosis
If invasive, (+) node metastases - almost always fatal
What is the MC cell type for vulvar cancer? 2nd MC? How common is it?
90% are squamous cell carcinomas
2nd MC are malignant melanoma
Uncommon - 4% of GYN cancers overall
Who is the MC pt for vulvar cancer? What is the MC cause in younger women? Older women?
poor, elderly and pts who have NOT had frequent medical exams
MC cause in younger women - HPV
MC cause in older women - chronic inflammation
What are the top 2 symptoms of vulvar cancer?
Vulvar pruritus and/or mass
can also have bleeding, pain or be asymptomatic
What does the appearance of vulvar cancer have to do with? What part of the body do SCC often rise? What are some possible appearance options?
Appearance varies with type of cancer
SCC - 65% arise in labia
Varies from large, exophytic, cauliflower-like lesion to small ulcers to elevated red velvety tumor
What is the tx for vulvar cancer? When do you need a pelvic exenteration?
Wide radical local excision with inguinal lymph node excision
If (+) lymph node metastasis - radiation recommended
if involvement of anus, rectum, rectovaginal septum, proximal urethra or bladder= pelvic exenteration
aka they take everything!!
What is the recommended f/u for vulvar cancer? What timeframe has the highest rate of reoccurence?
Every 3 months for 2 years
Every 6 months thereafter
80% of recurrences in 1st 2 yrs
What is VAIN? Where are lesions more commonly found? Associated with ___ and ____
Preinvasive Vaginal Disease
upper ⅓ of the vagina
½ to ⅔ of patients have been treated for CIN or VIN
How do you dx VAIN? should use ____ to help identify areas
colposcopy and biopsy
3-5% acetic acid solution then bx
What is the tx for VAIN based on category?
What is the follow-up recommendations for VAIN?
Often difficult to eradicate with only one treatment modality or treatment session
Must monitor closely every 4-6 months
How common are vaginal cancer? What is the MC cell type? Where does it most likely come from?
VERY RARE only 0.3% of gyn cancer
85% - squamous cell carcinomas
MC form of vaginal malignancy is extension of cervical cancer
What is the criteria to be considered vaginal cancer?
Only considered primary vaginal cancer if cervix is uninvolved or minimally involved
What are the 4 cell types of vaginal cancers?
Squamous Cell Carcinoma
Adenocarcinomas
Sarcomas
Melanomas
_____ vag cancer: May be exophytic or ulcerative and usually involves posterior wall of upper ⅓ of vagina
Squamous Cell Carcinoma
aka ulcer or califlower
____ vag cancer: MC primary vaginal cancer in young patients
Adenocarcinomas
_____ vag cancer: MC form is highly aggressive tumor in infancy or early childhood with polypoid, edematous “grape-like” masses at vaginal introitus
sarcomas
____ vag cancer: May also see in older pts - upper anterior vaginal wall
sarcomas
_____ vag cancer: MC arise from anterior surface and lower ½ of vagina and rare
melanomas
What am I? What dx?
“Grape-like clusters”
primary vaginal sarcoma
What is the MC symptom of vaginal cancer?How do you dx?
postmenopausal and/or postcoital bleeding
then vaginal discharge, mass and urinary symptoms. pain or leg edema if advanced
colposcopy and bx
What is the tx for vaginal cancer?
hysterectomy, vaginectomy, lymphadenectomy
+/- chemo and radiation
if invasive -> pelvic exenteration
What is the 5 year prognosis rate of vaginal cancer? Which kind is highly malignant and does NOT respond well to therapy?
77% stage I, 45% stage II, 31% stage III, 18% stage IV
Melanomas: do NOT respond well to therapy
